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Licensing and Certification Program

Applications for Primary Care Clinics

The following forms and documents are required for licensure and/or certification.

In addition to the forms below, you are required to submit additional documents for a change of ownership and for a Mobile Clinic. These documents must be submitted with your completed application. The required information and instructions are listed on the checklist contained in the Primary Care Clinic Facility Application Request Letter and Instructional Checklist (PDF) letter.

For an Affiliate Primary Care Clinic, the required information and instructions are listed on a separate checklist contained in the Affiliate Primary Care Clinic Facility Application Request Letter and Instructional Checklist (PDF) letter.

Primary Care Clinic - Community or Free Clinic (Including Mobile Clinic)

Required Forms to be Licensed:

Required Forms to be Certified with Medicaid/Medi-Cal:

Affiliate Primary Care Clinic – Community, Free or Mobile Clinic

Required Forms to be Licensed:

Required Forms to be Certified with Medicaid/Medi-Cal:

Contact Us:

Phone: (916) 552-8632

Email: CAU@cdph.ca.gov

Staff will respond to your inquiry within 48 hours.

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